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INTRODUCTION:Intraoperative cholangiogram (IOC) can define biliary ductal anatomy. Routine IOC has been proposed previously. However, as the “critical view of safety” technique has become widespread, current practice and outcomes of IOC are unclear.

METHODS: Nationwide Inpatient Sample 2004-2009 was queried for patients with acute/urgent biliary disease undergoing laparoscopic and/or open cholecystectomy; IOC was quantified. We limited analyses to states with consistent coding of provider and hospital ID data, and excluded surgeons performing <10 cholecystectomies/year. We dichotomized surgeons into a high-IOC group (top 10%, using yearly ratio of IOC/cholecystectomy frequency) vs. standard group (lower 90%). Our outcomes included bile duct injury, overall complications, in-hospital mortality, length of stay (LOS), use of additional studies such as endoscopic retrograde cholangiopancreatography (ERCP), and hospitalization cost. Statistical analysis included weighted univariable and multivariable analysis, and Cochran-Armitage trend test.

RESULTS: 518488 nationally weighted patients underwent cholecystectomy; 33.9% had IOC. Over time, IOCs utilization increased (31% to 34%, p<0.0001), annual number of cholecystectomies remained stable. 12,527 non-weighted annual surgeon volumes were included in analysis. On average, each surgeon performed 31.9 cholecystectomies and 7.9 IOCs annually, with mean annual surgeon-specific IOC/CCY ratio of 0.23. The high-IOC (top 10%) group used IOC for 100% of cases. Of note, 25% of surgeons used IOC for at least half of cases. Comparing high-IOC group to standard group, high-IOC had no difference in bile duct injury (0.25% vs. 0.27% for standard group, p=0.2; a higher rate of overall complications: 7.2% vs. 6.9%, p=0.04; and no difference in mortality 0.4% vs. 0.4% p=0.8). Patients of high-IOC surgeons had shorter LOS, 3.9 vs. 4.2 days, p=0.002, and were more likely to use additional procedures: ERCP 16.0 % vs. 13.1%, p=<0.0001.


CONCLUSION: IOC remains a frequently used procedure. In a national study, most surgeons appear to be using IOC selectively. A 10% minority of surgeons appear to approach IOC as mandatory. Intriguingly, a surgeon’s routine use of IOC is correlated with increased rates of post-surgical procedures, and is associated with increased overall complications, with no additional decrease in CBD injury rate. Further studies are warranted to determine if additional surgeon, patient, or perioperative factors contribute to the apparently unhelpful effect of compulsory IOC.